— 基本照護與舒適 · MEDIUM · MCQ —
護理師評估病人的疼痛管理成效。哪項發現最能說明病人感到緩解？
A nurse is evaluating the effectiveness of a client's pain management. Which finding best indicates that the client is experiencing relief?
- AThe client is sleeping soundly病人睡得很沉
- BThe client has stopped moaning病人已停止呻吟
- CThe client's heart rate is within normal limits病人之心率處於正常範圍
- DThe client reports a decrease in pain on a scale of 0-10✓ 正解病人報告疼痛量表（0-10分）上的疼痛程度降低
— Explanation · 中文詳解 —
疼痛是主觀的感受，臨床上病人的自我報告（Self-report）被視為評估疼痛的「金標準」（Gold standard）。護理師在評估疼痛管理成效時，不能僅依賴生命徵象或觀察行為，因為疼痛會因神經適應或個體差異而出現假性緩解。雖然生命徵象改變、呻吟減少或入睡可能與疼痛緩解有關，但這些皆屬於間接指標，可能受到鎮靜劑、藥物副作用或其他因素影響。因此，直接詢問病人對疼痛的感受，並參考疼痛量表（Pain scale）評分，是最精確的證據。
Self-report is the gold standard for assessing pain intensity because pain is a subjective experience. While behavioral cues and vital signs may change, they can be influenced by other factors; therefore, a client's direct rating on a pain scale is the most reliable indicator of pain relief.